Hypertensive Emergency Team-Based Learning

Audience The target audiences for this team-based learning (TBL) activity are resident physicians and medical students. Introduction According to the Centers for Disease Control and Prevention (CDC), nearly half of the adults in the United States have hypertension,1 which is a leading cause of cardiovascular disease and premature death.2 In extreme cases, patients may present in hypertensive emergencies, defined as an acute, marked elevation of systolic blood pressure >180mmHg or diastolic blood pressure >120mmHg with evidence of organ dysfunction.3,4 Patients presenting to the emergency department (ED) with symptoms of hypertensive emergencies must be promptly diagnosed and treated to prevent further morbidity and mortality. This TBL utilizes four clinical cases to educate resident physicians and medical students not only on the recognition of hypertensive emergencies, but also on the workup, management, and disposition of patients who present to the ED with hypertension. Educational Objectives By the end of this TBL session, learners should be able to: 1) define features of asymptomatic hypertension versus hypertensive emergency, 2) discuss which patients with elevated blood pressure may require further diagnostic workup and intervention, 3) identify a differential diagnosis for patients presenting with elevated blood pressures, 4) recognize the features of different types of end-organ damage, 5) review an algorithm for the pharmacologic management of hypertensive emergencies, 6) indicate dosing and routes of various anti-hypertensive medications, 7) choose the appropriate treatment for a patient who is hypertensive and presenting with flash pulmonary edema, 8) identify an aortic dissection on computed tomography (CT), 9) choose the appropriate treatment for a patient who is hypertensive and presenting with an aortic dissection, 10) identify intracranial hemorrhage on CT, 11) choose the appropriate treatment for a patient who is hypertensive and presenting with an intracranial hemorrhage, and 12) describe the intervention for warfarin reversal. Educational Methods This is a classic TBL that includes an individual readiness assessment test (iRAT), a multiple-choice group readiness assessment test (gRAT), and a group application exercise (GAE). Research Methods Learners and instructors were given the opportunity to provide verbal feedback after completion of the TBL. Learners included senior medical students and first-, second-, and third-year emergency-medicine residents. Learners were specifically asked if they felt the cases were educational, relevant, and useful to their training. Results Six resident physicians and three medical students volunteered their verbal feedback, and agreed when they were specifically asked if the cases were educational, relevant, and useful to their training. The same learners also agreed when asked if they felt the TBL was a more enjoyable activity than a direct lecture to refresh their knowledge and skills. One instructor observed that interns and medical students were generally able to reach a correct diagnosis; however, they seemed to struggle more with describing appropriate pharmacologic interventions when compared to more senior learners. Discussion Hypertension is a common complaint and incidental finding in patients presenting to the ED. Given its non-specific value, it can be a difficult topic for the novice healthcare provider to master. The differential diagnosis for a patient presenting with hypertension is vast, ranging from benign to emergent, and can sometimes necessitate minimal to substantial workups. Thus, this TBL is a useful, relevant, and effective exercise for residents-in-training to review and understand the management of hypertension. Topics Hypertension, hypertensive emergency, asymptomatic hypertension, flash pulmonary edema, aortic dissection, intracranial hemorrhage, warfarin reversal, team-based learning.


Objectives:
By the end of this team-based learning (TBL), learners should be able to: 1. Define features of asymptomatic hypertension versus hypertensive emergency.2. Discuss which patients with elevated blood pressure may require further diagnostic workup and intervention.

Identify a differential diagnosis for patients
presenting with elevated blood pressures.4. Recognize the features of different types of endorgan damage.5. Review an algorithm for the pharmacologic management of hypertensive emergencies.6. Indicate medication dosing and routes of various anti-hypertensive medications.7. Choose the appropriate treatment for a patient who is hypertensive and presenting with flash pulmonary edema.8. Identify an aortic dissection on computed tomography (CT).9. Choose the appropriate treatment for a patient who is hypertensive and presenting with an aortic dissection.10.Identify intracranial hemorrhage on CT. 11.Choose the appropriate treatment for a patient who is hypertensive and presenting with an intracranial hemorrhage.12. Describe the intervention for warfarin reversal.

USER GUIDE
Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP90 4 Hypertension is a common complaint and incidental finding in patients presenting to the emergency department (ED).Given its non-specific value, it can be a difficult topic for the novice emergency medicine resident to master.The differential diagnosis for a patient presenting with hypertension is vast, ranging from benign to emergent, and can sometimes necessitate minimal to substantial workups.Thus, this TBL is a useful, relevant, and effective exercise for residents in training to review and understand the management of hypertension by working through cases, including asymptomatic hypertension versus hypertensive emergency (objectives 1, 2, 3, and 4), a patient with flash pulmonary edema (objectives 5, 6, and 7), a patient presenting with an aortic dissection (objectives 6, 7, 8, and 9), and a patient on anticoagulation presenting with an intracranial hemorrhage (objectives 6, 7, 10, 11, and 12).

Results and tips for successful implementation:
This TBL was administered during a resident didactics session at University of California, Irvine, Department of Emergency Medicine.Although originally written to be implemented in a paper format, a digitized version of this activity was created on Microsoft Forms and utilized for this particular session.One emergency-medicine/medical-education fellow acted as the instructor.Learners included medical students and first-, second-, and third-year emergency-medicine residents.Learners and instructors were given the opportunity to provide verbal feedback after completion of the TBL.Learners were specifically asked if they felt the cases were educational, relevant, and useful to their training.
Six resident physicians and three medical students volunteered their verbal feedback and agreed when they were specifically asked if they felt the cases were educational, relevant, and useful to their training.The same learners also agreed when asked if they felt the TBL was a more enjoyable activity than a direct lecture to refresh their knowledge and skills.Some senior learners found the cases to be straight-forward.The instructor observed that interns and medical students seemed to struggle more with describing appropriate pharmacologic interventions when compared to junior and senior learners.
Moreover, the authors noted that creating a digitized version of this TBL allowed for greater opportunities for its implementation, such as in remote didactics or in asynchronous curriculums.We believe that this would greatly benefit neurodivergent learners and those who are unable to attend didactics sessions.This online version where learners can receive immediate feedback on their answers could also be utilized as a resource for independent studying.

Hypertensive Emergency TBL: Group Application Exercise (GAE)
Digital:https://forms.office.com/Pages/ShareFormPage.aspx?id=dGqfIFMJpE2HKkcxkbtXXbR94NwoakBJkvy9eJcaW6xUMU1ZR0xJNU szVkpGOTBCRFJMUjlIN1ZZUy4u&sharetoken=7wpTMKE2yTZSHzjERAoR Case 1 A 55-year-old male with a past medical history of hypertension and ischemic cardiomyopathy with reduced ejection fraction presents with severe shortness of breath.His symptoms started abruptly 30 minutes ago.He is not having chest pain, but does complain of a cough.On exam, the patient appears to be in severe respiratory distress and is diaphoretic.He has rales in bilateral lung fields and 1+ edema in bilateral lower extremities.

Hypertensive Emergency TBL: Group Application Exercise Key (GAE Key)
Case 1 A 55-year-old male with a past medical history of hypertension and ischemic cardiomyopathy with reduced ejection fraction presents with severe shortness of breath.His symptoms started abruptly 30 minutes ago.He is not having chest pain, but does complain of a cough.On exam, the patient appears to be in severe respiratory distress and is diaphoretic.He has rales in bilateral lung fields and 1+ edema in bilateral lower extremities.

Q2: What is your initial management, and what labs would you like to order?
• Airway, breathing, circulation.
• Airway -Assess to ensure the patient's airway is patent.The patient appears to be alert and oriented, but in distress.• Breathing -Provide 100% oxygen (O2) via non-rebreather mask initially.Call respiratory therapy to set-up for bilevel positive airway pressure (BiPAP).This patient has a history of heart failure; thus, heart failure exacerbation should be on your differential.• Circulation -At this time, the patient is hypertensive.2 large-bore intravenous lines (IV) should be established immediately and should be placed on a cardiac monitor.• Initial labs should include complete blood count (CBC), basic metabolic panel (BMP), troponin, B-type naturetic peptide (BNP), and an electrocardiogram (ECG).
In general, for treatment of acute heart failure, consider the mnemonic "PPV HAVoC."• CT head (non-contrast) should be ordered.In acute intracerebral hemorrhage, sensitivity is 95-100%.This patient is not sick.Some may argue that given her elevated blood and associated headache, the patient is potentially sick.However, according to the American College of Emergency Physicians, for patients aged 18 years or older who present to the ED with elevated blood pressure and without signs and symptoms of acute organ injury, routine screening and treatment of asymptomatic hypertension is not required, if they have good follow-up with a primary care provider.However, in patient populations with poor follow-up, screening and acute interventions may be indicated.
According to the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7), stage 2 hypertension is defined as systolic blood pressure greater than or equal to 160 mmHg or diastolic blood pressure greater than or equal to 100 mmHg. 22symptomatic," in this case, refers to the absence of signs of acute organ injury."Asymptomatic" patients may still have headache, lightheadedness, nausea, palpitations, epistaxis, or anxiety; however, these are not signs of end organ damage.Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up.In populations who have poor follow-up, emergency physicians may treat markedly elevated blood pressures in the ED and/or start that patient on long-term therapy.22 It is important to note that providers may sometimes feel pressured to correct an asymptomatic patient's elevated blood pressure by administering intravenous antihypertensive medications (IVAH).However, the use of IVAH based purely on numerical value and without any supporting evidence of their use may be harmful and has no proven value.24,25

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According to the 2013 ACEP Clinical Policy regarding asymptomatic elevated blood pressure, routine ED medical intervention for markedly elevated blood pressure is: a. Supported b.Not required c.Considered to have potential harm 4. According to the 2013 ACEP Clinical Policy regarding asymptomatic elevated blood pressure, rapid lowering of elevated blood pressure in the asymptomatic patient is: a. Supported b.Not required c.Considered to have potential harm LEARNER MATERIALS Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP908 The 2013 ACEP Clinical Policy recommends consideration of treating asymptomatic hypertension in all of the following populations except: a. Patients with poor follow up b.Patients with limited access to care c.Patients less than 18 years old d.Black patients e. Elderly patients 6.According to the 2013 ACEP Clinical Policy regarding asymptomatic elevated blood pressure, which screening test would most likely affect disposition?a. ECG b.Creatinine c. Troponin d.None of these alters disposition 7. Which of the following management steps does the 2013 ACEP Clinical Policy recommend for asymptomatic markedly elevated blood pressure?a. Screening for kidney disease b.Referring for outpatient follow-up c.Observation and repeat blood pressure measurement d.Rapid lowering of mean arterial pressure at 25% 1.The 2013 ACEP Clinical Policy regarding asymptomatic elevated blood pressure defines markedly elevated blood pressure as: a. Systolic blood pressure greater than or equal to 160 mmHg or diastolic blood pressure greater than or equal to 100 mmHg b.Systolic blood pressure greater than or equal to 180 mmHg or diastolic blood pressure greater than or equal to 110 mmHg c.Systolic blood pressure greater than or equal to 220 mmHg or diastolic blood pressure greater than or equal to 180 mmHg 2. The 2013 ACEP Clinical Policy regarding asymptomatic elevated blood pressure states that routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.According to the 2013 ACEP Clinical Policy regarding asymptomatic elevated blood pressure, routine ED medical intervention for markedly elevated blood pressure is: a. Supported b.Not required c.Considered to have potential harm4.According to the 2013 ACEP Clinical Policy regarding asymptomatic elevated blood pressure, rapid lowering of elevated blood pressure in the asymptomatic patient is: a. Supported b.Not required c.Considered to have potential harm LEARNER MATERIALS Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP90 10 5. The 2013 ACEP Clinical Policy recommends consideration of treating asymptomatic hypertension in all of the following populations except: a. Patients with poor follow up b.Patients with limited access to care c.Patients less than 18 years old d.Black patients e. Elderly patients 6.According to the 2013 ACEP Clinical Policy regarding asymptomatic elevated blood pressure, which screening test would most likely affect disposition?a. ECG b.Creatinine c. Troponin d.None of these alters disposition 7. Which of the following management steps does the 2013 ACEP Clinical Policy recommend for asymptomatic markedly elevated blood pressure?a. Screening for kidney disease b.Referring for outpatient follow-up c.Observation and repeat blood pressure measurement d.Rapid lowering of mean arterial pressure at 25% LEARNER MATERIALS Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP9011

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et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP9023 The 2013 ACEP Clinical Policy recommends consideration of treating asymptomatic hypertension in all of the following populations except: a. Patients with poor follow up b.Patients with limited access to care c.Patients less than 18 years old d.Black patients e. Elderly patients 6.According to the 2013 ACEP Clinical Policy regarding asymptomatic elevated blood pressure, which screening test would most likely affect disposition?a. ECG b.Creatinine c. Troponin d.None of these alters disposition 7. Which of the following management steps does the 2013 ACEP Clinical Policy recommend for asymptomatic markedly elevated blood pressure?a. Screening for kidney disease b.Referring for outpatient follow-up c.Observation and repeat blood pressure measurement d.Rapid lowering of mean arterial pressure at 25%

Q3:
At this point, what is your differential diagnosis for this patient and what do you think is most likely?• Emergent causes of chest pain o Acute coronary syndrome (ACS) o Aortic dissection o Coronary artery dissection o Myocardial rupture o Esophageal perforation o Pulmonary embolism o Tension pneumothorax • The differential diagnosis for chest pain is broad.However, given the patient's history of hypertension, tobacco and cocaine abuse, and his presentation with acute neurologic deficit, aortic dissection should be high on the differential.• The Aortic Dissection Detection Risk Score (ADD-RS) should be used to guide workup of low to moderate risk patients for whom acute aortic syndromes are in the differential diagnosis.One point should be added for each of the three categories that contain at least one feature.

Q3:
At this point, what is your differential diagnosis for this patient and what do you think is most likely?• Stroke-like symptoms o Hemorrhagic stroke o Ischemic stroke o Seizures/postictal paralysis o Hypoglycemia o Hyponatremia o Meningitis o Drug toxicity o Cerebral sinus thrombosis o Bell's Palsy o Conversion disorder • The differential for stroke-like symptoms is broad.However, this patient has multiple high-risk comorbidities for a stroke and is presenting with depressed GCS and hemiparesis.Hemorrhagic stroke should be high on the differential, especially given her anticoagulated status because warfarin use is a significant risk factor.• Hemorrhagic strokes are often clinically indistinguishable from ischemic strokes.o ECG's may show deep T-wave inversions and prolonged QT intervals.Q4: What imaging, if any, would you like to order?INSTRUCTOR MATERIALS Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP9035

Q2:
What labs/imaging/meds/interventions would you like to order?No labs or interventions are needed.This patient's history and physical exam are reassuring.In patients presenting with elevated BP, history and physical exam should focus on searching for signs of end-organ damage, paying particular attention to neurologic, cardiovascular, and pulmonary exams.Alarm signs of hypertensive emergency include, but are not limited to: o Chest pain o Respiratory distress, hypoxia INSTRUCTOR MATERIALS Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.

Is this patient sick, not sick, or potentially sick? Q2: What is your initial management, and what labs would you like to order? LEARNER MATERIALS
degrees Fahrenheit ( o F), heart rate (HR) 130, blood pressure (BP) 200/150, pulse oximetry (SpO 2 ) 86% on room air.

What imaging, if any, would you like to order? LEARNER MATERIALS
Bedside echocardiogram (ECHO): moderately decreased ejection fraction, positive for B-lines.Chest X-Ray (CXR): cardiomegaly with diffusely increased interstitial markings.Computed tomography (CT) or computed tomography angiography (CTA) of the chest: increased interstitial markings, no pulmonary embolism, consolidation, or dissection.

At this point, what is your differential diagnosis for this patient and what do you think is most likely? Q5: What is the treatment for this patient? LEARNER MATERIALS
A 60-year-old-male with a past medical history of hypertension presents with chest pain radiating through to the back and left-sided weakness.His symptoms started abruptly thirty minutes prior to arrival.The patient endorses tobacco use and occasional cocaine use.On exam, he appears in distress, has 4 out of 5 weakness of the left lower and upper extremities and is otherwise neurologically intact.Vitals: oral temperature 98.6 o F, HR 120, BP 186/104, RR 20, and SpO 2 95% on room air.

Is this patient sick, not sick, or potentially sick? Q2: What is your initial management, and what labs would you like to order? LEARNER MATERIALS
Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP9015

At this point, what is your differential diagnosis for this patient and what do you think is most likely? Q4: What imaging, if any, and additional workup would you like to order? LEARNER MATERIALS
Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP9016 Results: Computed tomography angiogram of the chest 5 Q5: What

are the next steps, what are the blood pressure goals, and what BP lowering agents would you choose? Case 3
An 83-year-old female with a past medical history of diabetes, hypertension, coronary artery disease, and atrial fibrillation on warfarin presents with hemiparesis and confusion that started after acute onset of a severe headache.On exam, the patient is obtunded, not following commands, withdrawing to painful stimuli on the right side, and her pupils are equal and reactive to light.Vitals: oral temperature 98.6 o F, HR 120, BP 218/111, RR 20, SpO 2 95% on room air. Q1:

Is this patient sick, not sick, or potentially sick? Q2: What is your initial management, and what labs would you like to order? LEARNER MATERIALS
Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP9018

this point, what is your differential diagnosis for this patient and what do you think is most likely? Q4: What imaging, if any, would you like to order? INSTRUCTOR MATERIALS
Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP9022 9• PPV = "positive pressure ventilation."Non-invasivePPVreduces cardiac preload(by increasing intrathoracic pressure) and reduces afterload o BiPAP o Begin with positive end-expiratory pressure (PEEP) of ~8cm H20 and slowly titrate upward • Hypotension correction (not indicated in this patient) • Afterload reduction in patients who are HYPERtensive.Nitroglycerin is the first-line medication in ADHF without cardiogenic shock.It reduces afterload and preload.o High-dose nitroglycerin.Start with 3 sprays sublingually (400mcg per dose) o Start a nitroglycerin infusion at 50-100mcg/min and titrate up by 20mcg/min every 10 minutes to 100-200mcg/min. 10o Continue titration until resolution of symptoms or SBP < 160 mmHg o At higher doses, nitroglycerin has greater vasodilation > venodilation • Volume status (diuresis vs. intravascular volume repletion) o IV furosemide 1-2x the patient's daily home dose should be administered o Diuresis typically occurs 30-60 minutes after initial IV administration • Cause (treat underlying cause) This patient's disposition should ultimately be an admission to telemetry level of care at minimum.
Any high risk exam feature § Evidence of perfusion deficit (pulse deficit, systolic blood pressure differential, or focal neuro deficit plus pain), new aortic insufficiency murmur (with pain), hypotension/shock 11 o Any high risk condition § Marfan syndrome, family history of aortic disease, known aortic valve disease, recent aortic manipulation, or known thoracic aortic aneurysm o Any high risk pain feature § Chest, back, or abdominal pain described as abrupt onset, severe intensity, or ripping/tearing o Nguyen K, et al.Hypertensive Emergency Team-Based Learning.JETem 2024.9(2): T1-38.https://doi.org/10.21980/J8BP9034

Is this patient sick, not sick, or potentially sick?
13• Can also consider CTA brain/neck to assess for vascular abnormalities • CXR may be helpful in ruling out infection o 20mg bolus over 1-2 minutes, repeat every 3-5 minutes until target blood pressure An 80-year-old-female with a past medical history of hypertension is referred to the emergency department from clinic for elevated blood pressure.She has a moderate intensity, diffuse headache that started gradually today.She denies chest pain, shortness of breath, and confusion.She has not missed any doses of her anti-hypertensives.On exam, she appears to be in no acute distress and is neurologically intact with a steady gait.Vitals: oral temperature 98.6 o F, HR 65, BP 195/104, RR 20, SpO 2 95% on room air.

At this point, what is your differential diagnosis for this patient and what do you think is most likely?
Focal neurologic deficits o Loss of vision o Altered mental status, seizures o Severe headache (think: "thunderclap") o OliguriaIn patients who complain of flank pain or oliguria, or in populations with poor follow-up, screening for an elevated creatinine level to identify kidney injury may be indicated.Before diagnosing a patient with asymptomatic hypertension, end-organ dysfunction or emergent causes of a patient's hypertension must be ruled-out.